Acs0703 Injuries To The Face And Jaw

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Acs0703 Injuries To The Face And Jaw

  1. 1. © 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 3 INJURIES TO THE FACE AND JAW — 1 3 INJURIES TO THE FACE AND JAW Seth Thaller, M.D., and F.William Blaisdell, M.D. Assessment and Management of Maxillofacial Injuries Tremendous progress has been made in the management of sification of malocclusion, which is more than 100 years old, patients with facial injuries. Reconstructive surgeons are treat- remains one of the most commonly used systems. The maxil- ing an increasing number of challenging facial injuries because lomandibular relation is determined by the position of the of excellent advances in the transportation of trauma victims mesiobuccal cusp of the maxillary first molar in relation to the and the regionalization of care in trauma centers. Although buccal groove of the mandibular first molar. Angle’s class I, or severe facial injuries are often associated with devastating cos- neutroclusion, exists when the permanent maxillary first molar metic and functional defects, reconstructive surgeons are is ideally positioned—that is, the buccal cusp of the maxillary achieving better long-term surgical results and are able to first molar and the mesiobuccal groove of the mandibular first repair certain injuries that were once considered nonrecon- molar occlude, resulting in a normal anteroposterior relation structible by employing craniofacial surgical techniques devel- of the maxillary and mandibular dentition. Angle’s class II, or oped through the pioneering efforts of Dr. Paul Tessier, of distoclusion, exists when the maxillary first molar is mesial Paris. These techniques include widespread subperiosteal (i.e., toward the midline) to the corresponding mandibular exposure, rigid internal fixation with miniature plates and first molar. Angle’s class III, or mesioclusion, exists when the screws, and widespread primary bone grafting. mandibular first molar is mesial to the maxillary first molar. AIRWAY ASSESSMENT Initial Survey Facial bone fractures, bleeding, loose Maxillofacial injuries are secondary to dentition, debris, and laryngeal injuries either blunt or penetrating trauma. can contribute to airway compromise. Motor vehicle accidents remain the most Accordingly, whenever there is any evi- common cause of facial injuries charac- dence of maxillofacial injuries, it is terized by bony comminution and dis- essential to monitor the airway status traction. However, penetrating injuries, carefully. If the patient is conscious, such as knife wounds, can cause exten- alert, and breathing at a rate of less than sive soft tissue injuries to skin and under- 20 respirations/min, without excessive airway secretions or lying nerves, blood vessels, parotid structures, and other struc- excessive hemorrhage, it can be assumed that the patient has tures of the upper aerodigestive system. Gunshot wounds can an adequate airway. cause devastating injuries that necessitate extensive flap recon- In a comatose patient with compromised vital reflexes (i.e., struction to provide satisfactory soft tissue coverage of the gag, cough, and swallow), an endotracheal tube must be insert- underlying bone. ed immediately to prevent aspiration. In the presence of On initial assessment, the physician must always pay special nasopharyngeal bleeding, major maxillofacial injuries, or cere- attention to correcting the most life-threatening problems, brospinal fluid leakage, nasal intubation should be avoided including an obstructed airway, bleeding, and shock [see 7:1 because of the potential for intracranial contamination. If there Life-Threatening Trauma, 8:3 Shock, and 1:4 Bleeding and Trans- is a possible fracture of the cribriform plate, either an orotra- fusion]. Patients with facial injuries often have multisystem cheal tube should be placed or a cricothyrotomy should be involvement; priorities in the evaluation and treatment of asso- performed. In an agitated or restless patient, only a single ciated significant injuries are discussed elsewhere. attempt should be made at inserting an endotracheal or naso- tracheal tube; if the attempt is unsuccessful, an emergency After establishing that the patient is stable, the exam- cricothyrotomy should be performed [see 7:1 Life-Threatening iner should quickly make note of lacerations and contusions, Trauma]. In slightly more elective circumstances, a deliberate extensive bony disruptions, loss of vision, malocclusion, tris- tracheotomy may be the optimal means of ensuring an ade- mus, and bleeding. quate airway. Cricothyrotomy and tracheotomy must never be In the evaluation of facial injuries, a quick analysis of occlu- taken lightly, because they can lead to significant complica- sion provides extremely important diagnostic information that tions. In addition, because newer treatment modalities using serves as the foundation for future fracture repair. Angle’s clas- rigid fixation decrease the time required for extensive maxillo-
  2. 2. © 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 3 INJURIES TO THE FACE AND JAW — 2 Assessment and Management of Maxillofacial Injuries Known or suspected facial injury Assess airway, breathing, and circulation. Airway compromise No airway compromise Perform orotracheal intubation, Assess for major cricothyrotomy, or tracheotomy. nasopharyngeal bleeding. Major nasopharyngeal No major bleeding bleeding Attempt control of bleeding by packing oropharynx or nasopharynx with anterior or posterior nasal packing. Bleeding is not controlled Bleeding is controlled Treat truncal and central nervous system injuries Transport patient to operating room for fracture reduction, • Evaluate facial injuries. ligation of external carotid • Suture facial lacerations. artery, or both. • Perform routine and specialized x-ray evaluations. Treat specific facial injuries • Eye and orbital injuries. • Maxillary injuries. • Mandibular injuries. • Soft tissue injuries.
  3. 3. © 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 3 INJURIES TO THE FACE AND JAW — 3 mandibular fixation, more conservative methods of airway In major maxillofacial injuries with extensive pharyngeal control are often indicated. bleeding, immediate airway access is mandatory, either with an If the respiratory rate is higher than 25/min or if there is evi- endotracheal tube or by cricothyrotomy. Once airway control dence that the airway is obstructed or compromised, the has been achieved, the patient should be brought to the oper- patient should be carefully monitored. When the respiratory ating room for reduction of gross bony injuries, which will rate increases to 30/min or higher, an immediate assessment of often stop uncontrollable hemorrhage. In those rare instances arterial blood gases should be made under close observation. when maxillofacial injuries are associated with serious and A respiratory rate higher than 35/min is an indication for both uncontrollable hemorrhage, it may be necessary to obtain intubation and respiratory support unless the cause of the access to the external carotid artery for ligation of the major rapid rate can be identified and immediately reversed. trunk or a branch if either is the source of bleeding [see 7:4 Injuries to the Neck]. MAXILLOFACIAL BLEEDING Once the airway has been satisfactori- ly stabilized, the next priority is to man- Definitive Evaluation age maxillofacial bleeding. There is a When there is no associated airway misconception that patients do not bleed compromise, facial injuries are a lower profusely from facial injuries and that priority than potential thoracic, abdomi- facial bleeding can be controlled easily.1 nal, or head injuries. Unfortunately, this is not necessarily always the case. In addition, because In fact, in the absence facial injuries themselves can be so striking, associated signifi- of airway compromise and severe hemor- cant hemorrhage can often be overlooked or underestimated. rhage, definitive diagnostic evaluation and management of Firm compression with moist sponges will temporarily stop maxillofacial injuries can be delayed until the more life-threat- most arterial and venous bleeding. Careful application of dig- ening injuries have been stabilized and treated. ital pressure or definitive ligation of the bleeding point can EXAMINATION often control external bleeding.These procedures are best per- formed in the operating room, with the patient under general Like any other anatomic region, the face must be examined anesthesia. in an orderly fashion, with careful attention paid to gross If the source of hemorrhage is in the depths of a narrow lac- asymmetry, paralysis, weakness, eye movements, occlusal dis- eration, bleeding can be controlled temporarily by packing. crepancies, and ecchymosis. Areas of hypesthesia or anesthesia Blind clamping or suture ligation can damage important should be noted. Special attention should be directed toward underlying facial structures, particularly branches of the facial bimanual palpation of bony prominences within the craniofa- nerve; therefore, such procedures must be avoided. Insertion cial region to look for crepitus, tenderness, irregularities, and of an anterior pack moistened with 1:10,000 epinephrine may step-offs. Palpation should start with the frontal bones and lat- be used to control nasal bleeding. However, persistent eral and inferior orbital rims. nasopharyngeal hemorrhage will necessitate either placement The zygomatic arch should be palpated for evidence of of a posterior pack or ligation of the internal maxillary artery depression, and the region of the malar eminence should be or the external carotid artery. evaluated for recession [see Figures 1 through 4]. Fracture of the Ecchymosis Flattened Cheek Figure 1 Broken nose. Figure 2 Fractured zygoma.
  4. 4. © 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 3 INJURIES TO THE FACE AND JAW — 4 Figure 3 Infraorbital fracture. Figure 4 Fractured mandible. zygomatic complex is often identified with an inferiorly dis- palpation of the mandible is accomplished by placing the placed lateral canthus, paresthesias of the infraorbital nerve, thumbs over the molar occlusal surfaces and the index fingers visual impairment, displacement of the globe, or trismus sec- externally over the inferior border of the mandible and ondary to impingement of the zygomatic arch on the coronoid torquing the bone to check for movement. Any missing or process or temporal muscle. mobile teeth must be recorded. The floor of the mouth should Orbital evaluation is key to the assessment of facial injuries. also be examined with bimanual palpation. The nasolacrimal duct should be inspected, and the distance The ears should be examined for evidence of lacerations or between the medial canthi should be measured for the pres- contusions of the external auditory canal that may be caused ence of telecanthus. (The normal intercanthal distance in the by condylar neck fractures. A simple diagnostic method is to average adult is less than 35 mm.) Pupils should be checked insert the fingertip into the external auditory canal on one for reactivity, and extraocular muscle motion should be side; if no movement can be determined with mandibular assessed. Diplopia secondary to extraocular muscle entrap- excursion, a diagnosis of condylar fracture can be made. ment should be determined. The position of the globe should FACIAL X-RAYS also be assessed; orbital floor fractures may cause enophthal- mos and severe swelling, and a blow-in type fracture may result A spectrum of available radiologic modalities plays a signif- in exophthalmos. A visual acuity test must be performed be- icant role in the diagnosis and treatment of facial injuries. fore any surgical intervention for correction of facial fractures. Appropriate studies are mandatory. In addition, x-rays provide An ophthalmologic consultation is essential if there is any evi- an excellent permanent record for medicolegal purposes. The dence of ocular damage, such as lens displacement, hyphema, initial x-rays of patients in the emergency room (the first level retinal detachment, acute visual impairment, or global disrup- for assessment and clarification of maxillofacial injuries) tion. should be performed using conventional films and should con- Next, the nose should be gently palpated. Any depression, sist of a cervical spine series (with all the cervical vertebrae abnormal motion, or deviation of the nasal bones and carti- adequately visualized), skull x-rays, and facial x-rays, including lages should be noted. The nasal cavity should be examined the anteroposterior, lateral, Waters, Towne, submentovertex, specifically for the presence of septal deviation, septal he- panorex, and mandibular views. More definitive x-rays can be matoma, or leakage of cerebrospinal fluid. A septal hema- obtained later for complete evaluation of specific injuries. The toma can be ruled out by aspiration with an 18-gauge or 20- Caldwell view defines the orbital walls and the frontal sinus gauge needle and syringe; if bleeding is present, an incision structures. The Waters view is important for determining the and drainage and placement of a drain are necessary. If left bony continuity of the orbit, nose, zygoma, and lateral portion untreated, a septal hematoma may lead to the development of of the maxilla. The lateral skull view is helpful for evaluation of a saddle-nose deformity. Flattening of the face, or dish-face frontal sinus fractures. Oblique views of the orbit are excellent deformity, is characteristic of midfacial fractures. for demonstrating the apex and the medial, lateral, and orbital Mobility of the maxilla is determined by placing one hand walls. over the bridge of the nose while the other grasps the palate The lateral oblique and modified Towne views are used to and upper dentition and moves the maxilla anteriorly and pos- evaluate the mandible.The lateral oblique is the most common teriorly, checking for separation of the midfacial structures. and useful view and provides evaluation of the body, angle of The mandible should be palpated carefully with both hands to the body, and the ascending ramus. A posteroanterior view is locate any intraoral mucosal lacerations or lesions. Bimanual helpful in assessing the symphyseal and body regions as well as
  5. 5. © 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 3 INJURIES TO THE FACE AND JAW — 5 the condylar and coronoid processes. Panoramic x-rays are the sue damage to already traumatized skin and lead to less scar best screening views for assessing mandibular fractures, espe- formation. cially within the condyles. Associated injuries to the dentition and supporting structures may necessitate dental spot films for NERVE INJURIES more specific information. The facial nerve is the nerve most vulnerable to maxillofa- cial trauma, and its function must be thoroughly evaluated OTHER STUDIES before the administration of any local anesthetic. In addition, Computed tomographic scanning can be of great value in facial nerve injuries result in the most serious functional dis- diagnosing the more complex traumatic injuries, such as crani- abilities and aesthetic defects. Sensory nerves, such as the omaxillofacial injuries and associated central nervous system infraorbital and supraorbital nerves, can also be involved in injuries. Computed tomography is used to evaluate most criti- traumatic injures; however, the associated hypesthesia causes cally injured patients with craniocerebral trauma, and the only minimal long-term disability. studies can easily be extended to include the patient’s facial Whenever the posterior half of the parotid gland suffers a skeleton with little additional risk. Both 3 mm axial and coro- deep laceration, it should be assumed that a major branch of nal CT cuts of the facial skeleton should be obtained, espe- the facial nerve has been divided, and the face should be care- cially for examination of the orbit. A lateral oblique scan fully examined. If there is a clean, sharp division of one of the through the midportion of the globe provides additional infor- five major trunks or of the proximal main nerve trunk, it can mation regarding the bony architecture of the orbit.This infor- be repaired immediately with microanastomotic techniques. If mation can be reformatted, and three-dimensional reconstruc- there is substantial nerve loss, the nerve ends should be iden- tions can be made for further evaluation. Magnetic resonance tified and appropriately tagged for future nerve grafting. If a imaging is proving to be of benefit in assessing both bony and nerve laceration occurs anterior to the region of the lateral soft tissue injuries. Arteriography may be needed to evaluate canthus, nerve repair is generally unnecessary because there is the source of a hemorrhage or to rule out major vascular sufficient crossover from the opposite side. Peripheral branch injuries. injury is manifest by inability to raise the eyebrow (frontal branch), inability to close the eyelids (malar), smoothness of the cheek (infraorbital), inability to smile (buccal), and inabil- Treatment of Soft Tissue Injuries ity to frown (marginal mandibular). Soft tissue injuries are most often the result of penetrating PAROTID DUCT INJURIES trauma but can also be the result of blunt trauma [see Treatment of Maxillofacial Fractures, below]. Any patients who The parotid duct is located between the parotid gland and need general anesthesia, such as a child or a patient with exten- the oral mucosa, opening opposite the second upper molar. sive complex lacerations involving deeper structures, should be Any deep laceration of the anterior parotid gland can damage treated in the operating room after appropriate evaluation of this duct. If there is a possibility that the parotid duct their overall status. Soft tissue injuries can involve nerves, is injured, the orifice of Stensen’s duct should be probed. parotid ducts, lacrimal ducts, and other critical facial struc- Should the probe enter the wound, division of the duct is ver- tures. Abrasions must be thoroughly cleaned, and lacerations ified. The proximal cut end of the duct can be located by ex- should be irrigated with normal saline and conservatively pressing saliva from the gland. A catheter should then be debrided as necessary. With deeply embedded foreign materi- passed through Stensen’s duct and through the area of lacera- al, debridement and irrigation must be particularly meticulous tion, and the duct should be repaired over the catheter [see and extensive to prevent residual cosmetic deformities. Derm- Figure 5]. abrasion is especially good for large involved areas. Most facial LACRIMAL DUCT INJURIES lacerations can be closed primarily with standard suturing pro- cedures [see 1:7 Acute Wound Care]. Antibiotic coverage is left to Whenever there is a laceration involving the medial canthal individual preferences; however, 24 hours of prophylactic peri- region, a lacrimal duct injury should be assumed. Acute recon- operative antibiotic coverage with a cephalosporin is strongly struction of the lacrimal duct is controversial. If both ends of recommended. The examiner must always consider the possi- the duct can be easily discerned, the severed ends should be bility of underlying injuries, and careful palpation and visual- realigned, splinted internally, and repaired. This procedure is ization of important underlying structures should be part of best accomplished over a fine Silastic rod. Dissection to locate the definitive wound evaluation and treatment. the residual parts of the duct should be delicate and meticu- Local anesthetic agents used in the head and neck region lous, because traumatic dissection can aggravate the injury and should always contain epinephrine for hemostasis. To decrease result in further permanent damage. pain and discomfort, the local anesthetic should be adminis- SCALP INJURIES tered through the margins of the wound rather than through the surrounding skin. Regional nerve blocks are preferred for When scalp injuries are repaired, extensive shaving is unnec- suture closure of lacerations involving the forehead, cheeks, essary. Scalp injuries can be associated with profuse bleeding lips, and chin.The forehead can be blocked by local infiltration because of the scalp’s extensive vascular supply. To obtain ade- of the supraorbital nerve, which is located just superior to the quate control of hemorrhage from the wound margins, closure eyebrow. The upper lip, side of the nose, and adjacent skin can can be achieved in a single layer with a running, locking 3-0 be blocked by anesthetizing the infraorbital nerve. Injection of chromic suture on a large cutting needle. Associated underly- the mental nerve, located between the first and second bicus- ing skull fractures are always a possibility, and the skull should pids, will anesthetize the lower lip and surrounding chin. be palpated and inspected through any full-thickness scalp Regional blocks also provide the advantage of minimizing tis- wound.
  6. 6. © 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 3 INJURIES TO THE FACE AND JAW — 6 Figure 5 Injuries to the parotid duct are repaired by passing a catheter through Stensen’s duct and through the area of laceration and then repairing the parotid duct over the catheter. EYELID INJURIES Repair of ear wounds should be done in three layers by using If the patient reports excessive eye pain, the initial examiner fine nonabsorbable sutures to approximate the cartilage and must always first rule out an associated ocular injury. In addi- the skin. If the ear is completely detached, the cartilage should tion, when faced with through-and-through lid lacerations, be preserved within a subcutaneous pocket in the mastoid the examiner must perform a very careful eye examination. region for future reconstruction. Lacerations of the eyelid should be meticulously repaired by Hematomas can occur secondary to the shearing of the approximation of the margins of the lid defect, followed by clo- vascular mucoperichondrium from the underlying cartilage. sure of the laceration in three layers. The conjunctiva may be These must be evacuated early, and a conforming pressure left unsutured if good apposition can be obtained by closing dressing should be placed to maintain the normal ear contour. the tarsal plate and the pretarsal muscles that occupy the mid- NASAL INJURIES dle layer, which is preferably closed with fine absorbable sutures. Fine nonabsorbable skin sutures are employed to close Through-and-through lacerations of the nose and near- the final layer. All skin sutures should be removed within 48 avulsion injuries are cosmetic problems. Because the nose is hours. When there is extensive tissue loss, it may be necessary extremely vascular, repair of these injuries should be especial- to use plastic techniques to mobilize sufficient conjunctiva for ly meticulous and done in layers.The cartilage and skin should closure. be aligned with fine nonabsorbable interrupted sutures. Absorbable sutures should be employed for repair of the EYEBROW INJURIES mucosa. Key cosmetic points (i.e., epidermal-mucosal junc- For optimal cosmetic results, the eyebrows should be closed tions, nasal fold junctions, or critical angles in jagged lacera- meticulously in layers with careful alignment of the eyebrow tions) should be sutured first to ensure that no deformity margins. Lacerations passing through the eyebrow should not results. be shaved; leaving them intact facilitates good plastic closure. Because the hairs of the eyebrow run obliquely to the surface LIP INJURIES of the skin, any incision for debridement should follow the line If the margin of the lip has been divided, the vermilion bor- of the eyebrows to avoid further loss of hair. der should be carefully identified and tattooed, and the first sutures should be placed to approximate this critical margin. EXTERNAL-EAR INJURIES A common problem in the treatment of lip injuries is that it If avulsions of the ear are properly repaired, the chances are may become more difficult to identify landmarks when they good that they will heal because of the highly vascular pedicle. are obliterated by local anesthetic injections or associated Circulation is maintained if even a small pedicle is present. edema.
  7. 7. © 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 3 INJURIES TO THE FACE AND JAW — 7 Treatment of Maxillofacial Fractures ZYGOMATIC FRACTURES Management of maxillofacial fractures can be extremely The zygoma is a tetrapod structure that forms the malar challenging. The common maxillofacial fractures include prominence and the inferior and lateral aspects of the orbit. nasal, mandibular, orbital, zygomatic complex, sinus (e.g., Fractures of the zygomatic complex should be repaired to pre- maxillary, sphenoid, ethmoid, and frontal), and maxillary frac- vent the development of serious aesthetic and functional tures (e.g., Le Fort I, II, or III). Management of these fractures deformities. Satisfactory stabilization requires three-point fix- often requires sophisticated specialty treatment involving plas- ation achieved through incisions placed within the regions of tic surgeons, ophthalmologists, neurosurgeons, otolaryngolo- the upper and lower lids and the upper buccal sulcus.23 gists, or a combination of these.2-7 MAXILLARY FRACTURES FRONTAL SINUS FRACTURES In 1901, maxillary fractures were classified by René Le Fort The frontal sinus region is prone to injury because of its into three types.24 Although the Le Fort classification system prominent location and relatively thin anterior bony wall.8,9 remains entrenched in the literature and serves as a basis for Injuries to the frontal sinus area require comprehensive treat- both communication and description, it is rare that patients ment, often with a team approach. The key to treatment lies in exhibit pure Le Fort fracture patterns. Instead, trauma sur- determining the status of the nasofrontal ducts.10,11 Patients with such injuries also require careful, regular, long-term fol- low-up care because potentially life-threatening complications, such as meningitis, osteomyelitis, and mucopyocele, may develop.12-15 NASAL AND NASO-ORBITO-ETHMOIDAL FRACTURES The nasal bone is the most commonly fractured facial bone.16 Before any treatment is embarked on, it is always help- ful to have the patient provide a preinjury photo of himself or herself so that it can be determined whether the nasal defor- mity is from the acute episode.17 If a patient is seen almost immediately after injury and the associated swelling and ecchymosis are minimal, closed reduction can be performed at once. Nasal bone fractures can be reduced simply by inserting a scalpel handle or large hemostat into the nostril; the fracture segments can then be elevated and relocated. Usually, the nasal cavity is packed with petroleum jelly gauze to maintain alignment of the fracture and nasal septum, and a malleable splint is taped over the nose to provide counterpressure and assist in maintaining alignment. Packing is removed within 48 hours. However, treatment is generally not urgent and, Figure 6 Le Fort I fractures (black line) affect the upper jaw depending on the individual situation, may be delayed for 7 to alone. In Le Fort II fractures (red line), the upper jaw and the central portion of the face are separated from the skull. 10 days. Naso-orbito-ethmoidal fractures generally occur secondary to direct force applied over the nasal bridge, resulting in pos- terior displacement of bony structures and involvement of the medial canthus, lacrimal duct, canaliculi, and sac.18 Repair of naso-orbito-ethmoidal fractures can be extremely challenging because of the number of important structures involved and their extensive comminution.19 Satisfactory surgical manage- ment should be conducted through a coronal approach, there- by permitting precise three-dimensional reduction and stabi- lization and extensive primary bone grafting for replacement augmentation.20 If there is associated CSF rhinorrhea, neuro- surgical assistance should be obtained and early fracture reduction done. ORBITAL FRACTURES Orbital fractures can occur as isolated events or as a com- ponent of more extensive injuries. Orbital fractures, such as lacrimal duct lacerations and injuries to the globe, require highly specialized management with the aid of an ophthalmol- ogist. Naso-orbital fractures with telecanthus should be treat- ed with open reduction and fixation, as should all displaced Figure 7 In Le Fort III fractures, all of the facial bones are fractures of the orbital rim and floor.21,22 separated from the skull.
  8. 8. © 2002 WebMD Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 3 INJURIES TO THE FACE AND JAW — 8 Figure 8 Findings in patients with Le Fort III maxillary fractures immediately after injury, before obliterative edema develops. geons are generally challenged by severe bony comminution and itive treatment results in a decreased number of complications. distraction. Preinjury occlusal relations remain the keystone to treatment. Le Fort I, or lower maxillary fractures, are the simplest type Mandibular fractures can be repaired by closed reduction with of maxillary fracture, consisting of horizontal detachment of maxillomandibular fixation or by open reduction and fixation the tooth-bearing segment of the maxilla at the level of the with wire osteosynthesis. However, newer techniques with rigid nasal floor [see Figure 6]. Le Fort II, or central or pyramidal internal fixation with miniature plates and screws have attained fractures, pass through the central portion of the face, which widespread popularity because of increased patient comfort.25-31 includes the right and left maxillae, the medial aspect of the In cooperative patients, a nondisplaced fracture can some- antra, the infraorbital rim, the orbital floor, and the nasal times be handled conservatively with a dental soft diet and bones. Le Fort III, or craniofacial disjunction, is characterized serial x-rays. by complete separation of all facial structures from the crani- um [see Figures 7 and 8]. Le Fort III fractures pass through the upper portions of the orbits as well as through both zygomas. All Le Fort fractures require highly specialized treatment that involves the use of craniofacial techniques, consisting of exploration and visualization of the entire fracture pattern, precise reduction, and rigid stabilization of bony segments. MANDIBULAR FRACTURES Diagnosis of mandibular fractures can usually be made on physical examination. Common findings include malocclu- sion, intraoral lacerations, and mobility at the fracture site. Radiographs are useful for planning treatment. Fractures of the mandible rarely involve the midline or symphyseal region. Most often, fractures will pass through areas of weakness, including the parasymphyseal region and the angle or neck of the condyle [see Figure 9].The fracture pattern is usually deter- mined by the site and mechanism of injury. Because of the mandible’s architectural arrangement, more than one half of mandibular fractures involve multiple sites. Mandibular fractures are not an emergency, but early defin- Figure 9 Mandibular fractures.
  9. 9. © 2002 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 7 TRAUMA AND THERMAL INJURY 3 INJURIES TO THE FACE AND JAW — 9 Discussion Because the face is so thoroughly exposed, it is one of the most sue, with minimal dead space and no tension. frequently injured areas of the body. Facial injuries can occur If the wound cannot be closed within the first 24 hours, under a variety of circumstances, such as automobile acci- delayed primary closure may be undertaken after 48 hours. In dents, altercations, or falls; more specifically, these injuries can this event, the patient should be given systemic antibiotics, and be the results of bites, fires, explosions, lacerations, and contact the wound should be kept moist and protected as much as pos- with sharp or blunt objects. In automobile accidents, shards of sible in the interval before closure. For best cosmetic results, glass may penetrate the wound, and these shards may not be the wound should be closed in multiple layers. radiopaque. If abrasions are present, note should be made of Sutures made of fine monofilament nylon, such as 6-0, are the abrading agent, whether it be grease, particles of dirt, grav- ideal for approximating the skin because they are nonreactive. el from a highway, or other contaminants. Underlying bony The sutures should be applied loosely so that they do not injury may or may not be obvious near the wounds. Because strangulate tissue. such injuries can expose the patient to tetanus or other anaer- Key anatomic points should be identified and tattooed, obic infections, antitetanic agents should be administered as mucosal edges should be approximated, and irregular margins part of the treatment regimen [see I:7 Acute Wound Care]. If of the skin should be excised and squared to provide the best treatment is delayed for any reason, a systemic prophylactic possible fit. Margins of damaged structures, such as the nose antibiotic should be administered. Minor lacerations of the or the ear, should be defined, and the critical margins should face caused by domestic assaults or household accidents can be determined and approximated initially. While the wound is be adequately treated in the emergency department under being closed, all dead space in the wound should be obliterat- local anesthesia [see I:7 Acute Wound Care]. Lacerations that are ed and the edges everted. If the needle is passed through the contaminated are often best treated in the operating room with skin at right angles, the edges of the skin will abut and eversion the patient under general anesthesia. will occur. If, however, the needle is passed through the skin Only as much hair should be removed as is necessary for edge obliquely, inversion will result, and healing will be com- adequate assessment of the wound or for effective suturing. promised. Subcutaneous or subcuticular sutures should be Eyebrows are best left unshaved to facilitate cosmetic repair. placed in such a way as to allow the skin edges to be approxi- Local anesthesia should be induced, and abrasions should be mated with minimal tension. If this procedure is done, scrubbed with a stiff brush until every particle of dirt is through-and-through sutures can be removed in 3 days, and removed. If the dirt is deeply embedded, some tissue may have no marks will be left on the skin. to be excised; this step can often be accomplished through the Any skin defects that require closure should be closed by use of a fine curette or the point of a No. 11 blade. If dirt is not grafting. No facial wound should be allowed to heal by granu- removed initially, it may be extremely difficult to remove later, lation, because this would lead to excessive scarring. Instead, a and permanent tattooing may result. temporary cover in the form of a skin graft should be provided Any dead or devitalized tissue should be excised, but there to minimize scar formation; any deformity that results from the is no place for radical debridement of facial wounds. Tissue graft can be repaired at a later date [see 3:7 Surface Recon- can survive on small pedicles. Full-thickness skin loss can be struction Procedures]. replaced with a free graft, which provides a better cosmetic The more complex of the maxillofacial fractures, such as match than a split-thickness skin graft [see 3:7 Surface Recon- major maxillary fractures, orbital fractures, malar fractures, struction Procedures]. If the wound is so ragged that it cannot be and mandibular fractures [see Treatment of Maxillofacial approximated, careful squaring of the edges may be advisable Fractures, above], must be treated with specialty techniques; to facilitate a cosmetic closure. Dead or devitalized subcuta- therefore, corresponding specialty consultation must be neous tissue should be removed conservatively. sought. However, in treating these fractures and soft tissue Most facial wounds can be closed by simple suturing. Al- injuries [see Treatment of Soft Tissue Injuries, above], the pri- though the deadline for closure of wounds to other sites is usu- orities are to ensure adequacy of the airway and to control ally 6 to 8 hours, facial wounds, unless heavily contaminated, immediate bleeding. Once these aims have been achieved, can be closed as long as 24 hours after injury, particularly if none of the defects described, except for facial lacerations, meticulous attention is paid to procedural details. Such details require emergency treatment; they can be repaired days to include irrigation of the wound, removal of all foreign bodies, even months later, if necessary, without jeopardizing a good excision of devitalized tissue, and accurate approximation of tis- cosmetic result.
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